Provider Demographics
NPI:1164874616
Name:CLEAR THE DERMATOLOGY CLINIC PC
Entity Type:Organization
Organization Name:CLEAR THE DERMATOLOGY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:RACIGNOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-348-2828
Mailing Address - Street 1:116 W MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2357
Mailing Address - Country:US
Mailing Address - Phone:231-348-0766
Mailing Address - Fax:
Practice Address - Street 1:116 W MITCHELL ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2357
Practice Address - Country:US
Practice Address - Phone:231-348-0766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-08
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053221208D00000X
MI5601004147363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty